3DPT Video Release Form

I hereby grant permission to 3 Dimensional Physical Therapy the rights of my image, in video or still, and of the likeness and sound of my voice as recorded on audio or video tape, without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

Photographic, audio or video recordings may be used for ANY USE which may include but is not limited to:

  • Presentations
  • Courses
  • Online/Internet Videos
  • Media
  • News (Press)

By signing this release, I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting.

I will be consulted about the use of the photographs or video recording for any purpose other than those listed above.

This authorization shall remain valid for three (3) years from the date of signing, unless revoked earlier in writing by the patient or authorized legal representative.

Revocation will prohibit future use or disclosure under this authorization but will not affect uses or disclosures already made in reliance on the authorization. IPTA Clinical, LLC will make reasonable efforts to discontinue its own ongoing promotional use following revocation. Materials already shared or distributed by third parties may not be fully retrievable.

This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only.

By signing this release, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.